Report: Immigrants Died in ICE Custody Because of Negligence, Still No Changes

Mauro Rivera Romero lasted three days in an Immigration Customs and Enforcement detention center in El Paso before he died.

Originally from El Salvador, 43-year-old Rivera was apprehended by U.S. Customs and Border Protection troopers at a Greyhound bus checkpoint in Texas. He told them he had just been released from a hospital two days earlier, suffering from a stomach infection and still experiencing stomach pain and nausea. But when border patrol transferred him to the detention center, they didn't explain that to medical staff. Rivera told the medical staff himself during his healthscreening, but couldn't remember the name of his medication, and according to an Office of Detention Oversight investigation, the medical staff failed to adequately review Rivera's medical records and should have immediately transferred him to a higher-level medical provider.

But they didn't. He saw a nurse 24 hours after writing his first complaint about the pain. Even though the nurse noted he had a pulse of 129, she did nothing. Rivera died less than 48 hours later.

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That was one of the eight cases the American Civil Liberties Union, the National Immigrant Justice Center and the Detention Watch Center closely examined in a new report on in-custody deaths at ICE detention centers. Since President Barack Obama took office in 2009, there have been 56 deaths at these detention centers. The report looks at 24 that occurred between 2010 and 2012 — eight of which internal investigators identified as preventable deaths, caused in part by staff negligence. Even more problematic, though, said ACLU staff attorney Carl Takei, who authored the report, was that despite investigators' in-custody death report findings showing that staff was partially at fault, ICE detention centers changed nothing in response, ultimately sweeping the findings under the rug.

“If this were a functioning system,” Takei said, “these death investigations would play a role closer to a hospital's postmortem analysis. When a patient dies at a hospital, and the hospital conducts a postmortem analysis, they don't just file it away. They use it to improve health care for the next patient who comes through the door. What we found is that is not what is happening at ICE. The oversight processes are broken, and that is deeply troubling,” Takei said.

Not long after taking office, Obama passed detention center reforms in 2009 that changed medical care standards and oversight, and also set up this in-custody death internal review process. Takei said that's why the cases are older, from 2010 to 2012, because even though the ACLU started the project in 2013, it had to take ICE through years of litigation before it even obtained the internal investigation reports. Despite Obama's reforms, though, the researchers found that 139 of the 250 ICE detention centers were still operating under pre-2009 or even pre-2000 standards.

In a statement, ICE said that since 2012, it has "simplified the process" for detainees to receive treatment (in one of the eight cases examined, filling out paperwork led to a one-hour delay before someone called 911). ICE said, "U.S. Immigration and Customs Enforcement (ICE) remains committed to providing a safe and humane environment for all those in its custody, including affording access to necessary and appropriate healthcare. ICE takes the death of any individual that occurs in the agency’s custody very seriously."

Of the eight cases researchers chronicled in detail, six occurred under the watch of privately run, for-profit detention centers, where Takei said accountability is often even worse, as we've reported on before. Most of the detainees also suffered far longer than three days. In one case at a privately run facility, a 54-year-old Mexican man died after 142 days of suffering from cardiomyopathy, a treatable heart-muscle disease. Over the course of his stay, he reported abdominal pain so severe that he hadn't slept in a month. Repeatedly, he reported daily vomiting, increased stomach pain after eating, and profuse sweating. During his visits with medical staff, they noted he could not finish a sentence without gasping for air. Despite all of this, he was not transferred to a hospital for four months. He died within two days.

In another case, at a detention center operated by the local sheriff's office, a 47-year-old Bosnian woman suffered 47 days of chronic bowel inflammation, rectal bleeding, vomiting, abdominal pain and heart arrhythmia. She was found unresponsive in her cell after seven days of not eating — facility workers had known she hadn't been taking meals but never reported that to medical staff. She was not given a full medical screening when she entered, and medical staff made no attempt to obtain her medical records until she had been incarcerated for more than a month.

“It's bad enough when a person dies a preventable death in detention,” Takei said. “But if the agency does not learn from that and change its policies and processes to prevent that from happening again, that means that immigration detention will continue to be a death sentence for future people in detention.”